HomeMy Public PortalAbout5115 FARAGO AVE_Mechanical__ ION
WORKER'S I have
a certificate
of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LANE GREET,
76A364C
' I hereby affirrP that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.)
Policy No.,&�� Company � /�!/ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS . BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUMIN
Q
dep4ment.dep menl. /C�' (PRINT OR TYPE ONLY)
Date Applicant (/�N t /P�/ LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST h
//RREE„���r// CROSS S —�!'J' /tT �� /�7(/
COMPENSATION INSURANCE J ABSORPTION UNIT,BTU
SSOR
(This section need not be completed if the wor involved by the M PEBOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY ,
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person.in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws. ��
Ya COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APP CANT: If, after making this Certi cats of ROUGH t
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL'
provisions or this permit shall be deemed revoked. FURNACE: FAU G AVITY JI VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and. WALL
Professions Code,and my license is in full force and effect.
License Number L Lic.Class
�q ' d
Contractor g, Date— �' Q
1 am exempt under-Sec. Plan Check fee
B.BP.C.for this reason PERMIT ISSUING FEE$X7 0
Date: TOTAL FEE W
Signature n-
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business'and Professions
Code): ADDRESSJL
F1 I, as owner of the property, or my employees with wages A�•t•T.'
as their sole compensation, will do the work and the CITY TEL.NO. 3307 109 rc
structure is not intended or offered for sale (Section 7044, 1� ` i T
Business and Professions Code). OWNER ;./A Q ��� 1ITEMS hi tS -
0 1, as owner of the property, am'exclusively contracting MAIL TI�TAL.
-55
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). CITY ,y n� TEL.NO. CHECK 109°55
CONSTRUCTION LENDING AGENCY _Ce1rav M V. CHANGE
�15I
I hereby affirm that there is a construction lending agency for G 4fitt °-.
theperformance of the work for which this permit Is issued CONTRACTOR
(Sec. 3097,,Civ.C.).
ADDRESS, _
Lender's Name0000-0001 8/20/9
, 611 I AN Q o 1j
CITY TEL.NO.
Lender's Address STATE LIC. n
I certify that I have read this application and state that the above LICENSE NO. CLASS v'
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
property or inspection oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
J>—
SIGNATr 1511APP1 ICANT OR A(32�r DATE f '